P2.M248: Pediatric Stroke Complicated by Meningitis and Ventriculomegaly: A Case Study of Early Intervention and Complex Management

Introduction: Pediatric strokes are relatively rare but pose unique challenges due to their significant impact on development and the complexities of management. The incidence of acute ischemic stroke is estimated as 1 in 3500 live births in newborns and between 2 per 100,000 children (Ferriero et al,2019). This case report details the clinical course of a four-month-old infant who experienced an ischemic stroke. Since this case was subsequently complicated by meningitis and ventriculomegaly, there is convincing evidence for prompt diagnosis and intervention.

Case Description: A 4-month-old female infant presented with acute symptoms, including left-sided weakness, right-sided facial drooping, vomiting, irritability, and lethargy. Her mother confirmed the absence of seizures. The patient was born prematurely at 35 weeks due to maternal preeclampsia and required a 10-day NICU stay post-delivery.

Initial examination revealed right-sided facial weakness, left-sided hypertonia, heightened deep tendon reflexes on the left, and reduced sensation, indicating significant neurological involvement. Laboratory findings suggested an inflammatory process, with elevated white blood cell count (11.2 x 10^9/L) and C-reactive protein (167 mg/dL). Imaging studies confirmed an ischemic stroke affecting the anterior and middle cerebral arteries (Image 1).

Administration of aspirin and intensive cardiorespiratory monitoring was the initial treatment. however, complications developed rapidly. Intracranial hypertension that was unresponsive to Diacarbine manifested on the first day post-admission, necessitating a right-sided decompressive craniectomy. The patient received additional treatments including midazolam, vancomycin, fentanyl, paracetamol, ceftriaxone, and norepinephrine to stabilize hemodynamics.
Her condition worsened on day 12, presenting with fever, irritability, and leukocoria, diagnosed as bacterial meningitis. Despite antibiotic adjustments and increased doses, her condition declined. Treatment shifted to include a fourth-generation cephalosporin and ampicillin, alongside continuing colomycin.
Subsequent ultrasounds and MRIs confirmed ongoing ventriculomegaly and cystic encephalopathy (Image 2). At the time of this report, the patient remained hospitalized under continuous monitoring, awaiting recovery of her symptoms.

Discussion: This case illustrates the complexity and rapid progression of acute ischemic stroke to severe neurological symptoms in pediatric patients. Due to their rarity, these cases garner significant clinical interest. Current understanding is mainly based on adult models, with limited pediatric-specific research, especially concerning management strategies for complications like post-stroke meningitis.
It emphasizes the need for vigilant monitoring and prompt management. This case challenges current protocols by presenting a scenario where standard interventions were insufficient.

Conclusion: The presented case highlights the critical nature of immediate and aggressive treatment strategies in managing pediatric stroke complicated by meningitis and ventriculomegaly. It also underscores the importance of developing and refining guidelines for pediatric-specific research to improve outcomes in this vulnerable population. This case not only reaffirms the complexities associated with pediatric strokes but also contributes valuable insights into the integrated care approach necessary for managing severe complications.